=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689262818
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALEKSEY KOZLOV, D.M.D., LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2021
-----------------------------------------------------
Last Update Date | 01/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 BIRCH ROAD
-----------------------------------------------------
City | CEDAR CREST
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-281-2622
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13150 WENONAH AVE SE APT 521
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87123-3857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | DR. ALEKSEY KOZLOV
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 916-247-2048
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------